Overview of

The International Classification

of Diseases, 9th Revision, Clinical
Modification (ICD 9-CM)

Procedure Classification
 History
• ICD 9 (1975)
Volume 1 – Tabular List
‘E’ Code – supplementary classification of
external causes of Injury and
Poisoning
‘V’ Code – supplementary classification of
Factors Influencing Health Status and
Contact with Health Services

Volume 2 – Alphabetic Index

 History
 ICD 9-CM (1978)
- Introduced by US (Commission of Professional &
Hospital Activities)
 3 volumes:
Volume 1 – Diseases : TABULAR LIST
Volume 2 – Diseases : ALPHABETICAL LIST
Volume 3 – Procedures: TABULAR and ALPHABETICAL
LIST
Specification of ICD-9-CM
 ICD-9-CM Klasifikasi Tindakan diterbitkan dalam
satu kesatuan yg terdiri dari Tabular List dan
Alfabetical Index
 Klasifikasi Tindakan dalam ICD-9-CM merupakan
modifikasi dari ICOPIM - Oktober 1975
 Tiga digit yang digunakan antara 01 - 86 disusun
seperti dalam ICOPIM.
 Klasifikasi didasarkan pada struktur dua digit
dengan tambahan 2 digit desimal bila diperlukan.
4/28/2019
Specification of ICD-9-CM
 Struktur dalam klasifikasi sebagian besar
didasarkan pada struktur anatomy tubuh manusia.
 Menggunakan numeric

4/28/2019
 ICD 9-CM Procedure Classification:
1. Published in its own volume containing both Tabular List and
Alphabetic Index.
2. Modification of Fascicle V “Surgical Procedures” of ICD 9
Classification of Procedures in Medicine
3. Surgical procedures are group in rubrics 01-86
4. Non-surgical procedures are confined to rubrics 87-99
5. Structure of the classification is based on anatomy rather than
surgical specialty.
6. Numeric only
7. Based on 2-digit structure with 2 decimal digits where necessary
(expansion from 3 digits in ICD 9 to 4 digits in ICD 9-CM)
 Definition

Operative procedure

Non-Operative procedure
 Operative procedure
 An operation - defined as any therapeutic or major
diagnostic procedure which involves the use of instruments
or the manipulation of part or parts of the body and generally
takes place under O.T conditions. Any procedure undertaken
in the O.T and/or under G.A, other than the normal delivery
of an obstetric patient, is to be included.

 Principle Operation – performed to treat the condition

selected as the principle diagnosis
 Non-Operative procedure

 Other investigative and therapeutic procedures which does

not involves operation such as radiological, laboratory,
physical, psychological and other procedures.
Specification of ICD-9-CM
 ICD-9-CM Klasifikasi Tindakan diterbitkan dalam
satu kesatuan yg terdiri dari Tabular List dan
Alfabetical Index
 Klasifikasi Tindakan dalam ICD-9-CM merupakan
modifikasi dari ICOPIM - Oktober 1975
 Tiga digit yang digunakan antara 01 - 86 disusun
seperti dalam ICOPIM.
 Klasifikasi didasarkan pada struktur dua digit
dengan tambahan 2 digit desuimal biola
diperlukan.
Specification of ICD-9-CM
 Struktur dalam klasifikasi sebagian besar
didasarkan pada struktur anatomy tubuh manusia.
 Menggunakan numeric
TABULAR LIST of ICD-9-CM
1. Operation on Nervous system
2. Operation on Endocrine System
3. Operation on Eye
4. Operation on Ear
5. Operation on Nose, MOUTH and Pharynx
6. Operation on The Respiratory System
7. Operation on cardiovasculair System
8. Operation on Hem,ic and Lymphatic System
9. Operation on the Digestive System
10. Operation on the Urinary System
11. Operation on the Male Genita Organ
12. Operation on the Female Genital Organ
13. Obstetrrical Procedures
14. Operation on the Musculoskeletal system
15. Operation on 5teh intergumantary system
16. Mescellaneous Diagnostic and
Theraupetic Procedures.
 ICD-9-CM Procedure
New chapter (1)
0. PROCEDURES & INTERVENTIONS , NEC (00)
00.0 Therapeutic ultrasound
00.1 Pharmaceuticals
00.2 Intravascular imaging of blood vessels
00.3 Computer assisted surgery [CAS]
00.5 Other cardiovascular procedures
00.6 Procedures on blood vessels
00.9 Other procedures and intervention

New codes (114)

Invalid codes (4)

Revised code titles (15)

Revised others (???)

 Coding the Procedures
(ICD – 9 CM)
All SIGNIFICANT procedures should be listed
.
 Include both diagnostic and therapeutic
 Include significant non-surgical or non-operative
procedures for e.g. CT Scan, MRI

Code any procedure that:

 All procedures done in OT
 All procedures done outside OT but require
skilled staff and expensive equipment
 Do not include ………

 Nursing procedures
 Routine procedures
 Procedures that do not require specialised staff
 Procedures that do not require special equipment
 Examples of procedure that can be
excluded ………
 Ordinary plain X-Rays
 Ward catheterization;
 Cardiopulmonary resuscitation;
 Transfusion of blood UNLESS it was the reason for admission;
 Cardiac massage;
 Medication UNLESS psychiatric or cytotoxic;
 Laboratory tests or procedures;
 IV Therapy unless for dehydration;
 Anesthetic UNLESS for pain relief;
 Adjunct treatment such as physiotherapy
 Steps for Coding:

1. Identify the diagnostic phrase to be coded

2. Decide the Lead term
3. Look up lead term in the Alphabetic index
4. Locate any modifiers
5. Check the code given in the index with Tabular
list
6. Check for Inclusion and Exclusion terms
7. Assign the code
 Case-Mix takes into account:

Diagnosis Procedures
- primary - primary
-secondary Clinical - secondary
Co-morbidities pathways Treatment
Complications Medications
Age X-ray, Labs
Sex Length of stay
Severity Complications
Co-morbidities

Clinical characteristics Resources

DRG Decision Tree
SUFFIXES OPERASI
Suffix Arti Contoh
-desis : ikat, fiksasi arthrodesis, spondylodesis
-ectomy : operasi mengangkat, eksisi
appendectomy,
nephrectomy
-pexy : bedah fiksasi hyeteropexy, orchidopexy
-plasty : bedah koreksi, angioplasty, dermatoplasty
perbaikan
-(r)rhaphy : suture (jahit) herniorrhaphy, hepatorrhaphy
-(o)stomy : membuat lobang baru colostomy, ileostomy
-(o)tomy : insisi ke dalam craniotomy, tympanotomy
-tripsy : menghancurkan lithotripsy
24
Coder must be careful
Never underestimate the power
of wrong Clinical Code
The Coders Role
Recommendation 151 - Kennedy Report

….competent staff, trained in clinical coding, and

supported in their work are required: the status,
training and professional qualifications of clinical
coding staff should be improved.
 Audit/Trainer

Coding Certificate

Speciality Workshops

Refresher Workshops

Foundation Training
LATIHAN 1

 Contoh istilah-istilah procedure

1. dermatoplasty  dermat/o- plasty = operasi perbaikan
kulit
2. angioplasty  =
3. spondylodesis  =
4. hysteropexy  =
5. herniorrhaphy  =
6. colostomy  =
7. craniotomy  =
8. Gastrectomy =
9. orchidopexy  =
10. lithotripsy  =

29
LATIHAN 2
Gunakan unsur kata di bawah ini untuk menyusun suatu
istilah medis dan tulis arti istilah yang terbentuk;
Cpntoh: arthr/o- -desis  Arthrodesis = perlengketan
sendi
Root Suffix Istilah Arti:
card/i- -ectomy
crani/o- -pexy
cyst/o- -plasty
dermat/o- -(r)rhaphy
gastr/o- -(o)stomy
hepat/o- -(o)tomy
lith/o- -tripsy
nephr/o- -optosis

30
 Underline the Lead Term
1.Lower segment caesarean section secondary to Fetal Distress

2.Mid forceps delivery with episiotomy

3.Herniotomy for indirect inguinal hernia

4.Ritual Circumcision
5.Computerized Tomography Scan of Brain
6.Total Abdominal Hysterectomy & Bilateral Salpingo-oophorectomy

7.Debridement of Sequestrum of Tibia

8.Termination of pregnancy by aspiration curettage

9.Ultrasonography Uterus
10.Closed reduction of fractured humerus
SOAL LATIHAN (Cari Kode Procedure)
1. Appendicitis acut dengan Operasi pengangkatan appendix 
Appendectomy
2. Kanker rahim dilakukan pengangkatan rahim
(Hysterectomy)
3. Ibu melahirkan bayi tunggal dengan sectio cesarean
4. Fractur humerus dilakukan pemasangan pen
5. Sterilisasi pada pria
6. Pengangkatan kedua tuba falopian
7. Herniotomy
8. Pengangkatan tonsil dengan adenoidectomy.
9. Insisi dan drainase sinus cranial
10. Pengambilan benda asing yang masuk ke bronchus tanpa insisi.

4/28/2019